The most striking aspects of almost all political parties' health manifestos – with the exception of the ANC and the Democratic Alliance (DA) – are their limited and superficial understanding of health and how general their promises are, says Mark Heywood, the head of social justice organisation Section27. "Few of these manifestos start with any attempt to understand the current state of the health system or what sort of intervention is required to improve the health system."
Heywood said the ANC's manifesto is the "most properly considered" because it contains "specific commitments for which communities can hold it directly accountable". For example, the ANC promises to deliver chronic medicine closer to state patients' homes. Over the next five years, the party says, such patients will receive their medication at selected points – such as community pharmacies and private medical doctors – with the first 500 000 people benefiting from the roll-out of this programme this year.
Under the National Health Insurance (NHI) scheme, the ANC undertakes to build 213 clinics and community health centres, and 43 hospitals. It will double the number of HIV-infected people on antiretroviral therapy, from 2.4-million to 4.6-million, and ensure that all grade four girl children in schools are vaccinated against the human papilloma virus, which causes cervical cancer. The health department says the latter is the cancer that kills most South African women and is mostly detected too late to save women's lives.
But Heywood added: "What, however, makes me sceptical about the ANC's promises is that, unless there is a commitment to deal with crime and corruption, many of the party's commitments won't materialise. From the past five years we've learned that one of the biggest impediments for the delivery of healthcare services is corruption, particularly at provincial health department level, and the mismanagement and corruption of health MECs and senior staff."
In its manifesto the ANC declares that the NHI will be "publicly funded and administered". This has worried the country's 92 private medical schemes and 27 medical scheme administrators: they are afraid the NHI will render their services redundant.
Humphrey Zokufa, the chief executive of the Board of Healthcare Funders, which represents the medical scheme industry, said schemes and administrators want to know to what extent the ANC is going to engage with the private sector to assist with collecting and managing money on behalf of the NHI.
"The NHI is going to be a national health fund that collects money and pays for healthcare services from service providers. That's exactly what medical schemes and medical scheme administrators do," Zokufa argued. "If 'publicly administered' means the ANC would like to do this thing on its own, I've got my reservations about it."
Heywood said the DA's proposal to conduct a full review of "the nature and scale of vacancies in the public health system" and then to work with tertiary education institutions to fill "human resource gaps" is sensible, because "it attempts to first try to understand the state of the health system".
The party's suggestion to "develop standardised response times for emergency medical services", Heywood says, is also a practical proposal, "because there has been widespread concern with regard to the quality of ambulance services that presents a dilemma for the Constitution's promise that no South African may be refused emergency medical treatment".
On the other hand, Phophi Ramathuba, who heads the South African Medical Association's public-sector doctor component, maintains that the DA wants to "protect" the private healthcare industry.
"The DA has all these plans for the public sector but is not addressing how we can reduce the out-of-control and ever-increasing private healthcare costs … How is the DA going to redistribute funding to the public healthcare sector?" she asked.
Although the ANC commits to reducing private healthcare costs, Zokufa said more should have already been done in this regard.
"It's interesting that we regulate the prices of petrol, water, electricity and telecommunications. We see the logic of it. Yet health services, which are far more important to South Africans' survival than many of these commodities, go unregulated, with doctors and private hospitals being allowed to charge whatever they want."
According to the manifesto of the Economic Freedom Fighters (EFF), the party wants to build a "state pharmaceutical company" and a "state-owned healthcare equipment company" to manufacture medicines and healthcare equipment locally. The EFF also plans to "expedite the implementation of the NHI" and "send a minimum of 5 000 young South Africans per annum to train as doctors in the best universities across the world". Moreover, it vows to produce "essential generic medicines without regard to intellectual property right regimes".
Reacting to this, the head of the University of the Witwatersrand's school of public health, Laetitia Rispel, commented: "What I find interesting is the direct contradiction between the creation of state companies and use of international universities … this notion that it's possible and feasible to have state-owned companies that produce every single medication that you need and every single piece of equipment, but, while we have some of the best medical schools in the world, you outsource the training of doctors, and don't consider the local schools good enough to train more doctors."
Heywood maintained that the number of young doctor trainees, 5 000, as mooted by the EFF, is "clearly sucked out of nowhere. Why not train 3 000 additional doctors in South Africa every year in our existing medical schools, because then you will have doctors who are trained in our health circumstances. "If a party says, 'We're going to talk to the medical schools and propose to increase enrolment by up to X amount of doctors by say, 2020, in order to meet an existing deficit of X, then that's a serious proposal. The EFF's proposal is really just a 'thumbsuck'."
The health department says for the past decade South Africa's eight medical schools have trained about 1 200 doctors annually.
Heywood doubted that the EFF would ever produce generic medicines without regard for intellectual property rights. "It's a rushed promise; they're just trying to say something sexy. If they were to try to do that their government would get smashed pretty quickly. So, it's a populist statement," he said.
Zokufa added: "The EFF clearly doesn't understand international trade agreements. If South Africa doesn't respect the Trade Related Aspects of Intellectual Property Rights (Trips) agreement, to which the country is a signatory, no brand- name company would want to bring their products here, including products outside of the health field."
Heywood said the Congress of the People's suggestion to create "automated queues" in public health clinics shows a lack of insight into the conditions under which clinics operate. "What happens in clinics without electricity? Automated queues sound like a good thing, but outside of an understanding of the health system and a proper plan, it's really just a throwaway promise."
Rispel agreed: "It shows the party doesn't understand our health system because putting in an automatic queuing system if you don't have enough doctors or nurses to staff it is not going to make any difference."
The African Christian Democratic Party (ACDP) wants to make Aids a notifiable disease – a disease for which the law requires doctors to report it to public health authorities at the time of diagnosis. This is an extremely controversial issue in the HIV sector.
Heywood said: "It reveals the ACDP's ignorance of the poor-quality reporting systems we have. TB is a notifiable disease and we don't get good data. Making Aids a notifiable disease won't give us new data and it in fact threatens human rights, because it very often involves a breach of confidentiality as patients' confidential information is entered into a database."
The ACDP also wants to "prioritise public awareness campaigns to promote abstinence from premarital sex and infidelity", which, according to Heywood, won't work. "Research has shown that moral approaches don't work in HIV prevention. It's no good promoting things that go against human nature. And I'm afraid, for the vast majority of South Africans, abstinence is not an option; public health messaging and information on how to protect themselves against HIV with condoms is," he insisted.
The National Freedom Party (NFP) proposes a TB grant to "all citizens who are receiving TB treatment to ensure adequate nutrition". According to Ramathuba, this proposal reveals a serious lack of insight into the health system.
"TB patients already receive disability grants, so I'm not sure why the NFP wants to reintroduce the grant. In any case, the grant is not working as it incentivises people to stay sick and not take their treatment correctly. A better way to deal with it would be to provide patients with a food package."
People's health manifesto
Meanwhile, only eight of 20 political parties responded to health questions of the Treatment Action Campaign's (TAC) "People's Health Manifesto". The TAC asked parties to respond to 11 health-related questions such as "What concrete steps will your party take to bring an end to stock-outs of essential medicines?" and "Does your party support the provision of both condoms and comprehensive sex education in schools?"
Agang SA, the Azanian People's Organisation, the Democratic Alliance, the Freedom Front Plus (FF+), the Inkatha Freedom Party, the Pan Africanist Movement, the Patriotic Alliance and the United Democratic Movement responded by the deadline of late Wednesday afternoon. The ANC responded late Wednesday night. Agang SA supported the distribution of condoms at schools, saying "ignorance is the enemy of empowerment". But the FF+ said "condoms should rather be distributed at clinics and community centres". The ANC said "sexually active learners are [already] provided with contraceptives in one-to-one interactions with school health nurses or referred to clinics where contraceptives, inclusive of condoms, are provided".
High profile parties such as the Congress of the People (Cope) and the EFF failed to respond.
"We engaged extensively with these parties, both telephonically and by email, to try and get them to respond. They have had sufficient opportunity and appear not to have considered our request to be of high enough priority," the TAC said in a press release. "While Cope indicated a willingness to respond, they failed to do so. The EFF initially indicated a willingness to respond, but then claimed not to have heard about the manifesto."
Mia Malan is the health editor of the Mail & Guardian and director of the Bhekisisa health journalism centre.
